Medical Inquiry Form
Michigan Technological University
Institutional Equity (906) 487–3310
To the Medical Professional:
Does the employee have a qualifying disability that limits a major life function? YES NO
Does the disability affect the employees ability to perform the essential functions of the job? YES NO
Is the impairment permanent? YES NO
Please attach a letter regarding the medical condition(s) of the employee in reference to their request for
accommodations based on the ADA (Americ
ans with Disabilities Act). In this letter to Institutional Equity, please
address the following:
1. Please indicate how the disability limits the employees performance of essential functions of the position.
2. Identify possible accommodations that may enable the employee to perform the essential job functions.
3. How will your suggestions improve the employee’s ability to perform the essential job functions?
4. How long do you expect this accommodation to be necessary? Please provide any additional comments regarding
the length of accommodations.
Medical Professional’s Signature: Date:
Under the Americans with Disabilities Act an individual with a disability is a person who:
Has a a physical or mental impairment that substantially limits one or more of the major life activities;
Has a record of such an impairment or;
Is regarded as having such an impairment.
*Reasonable Accommodation: A reasonable accommodation is any change in the work environment or in the way things are usually
done that result in equal opportunity for an individual with a disability. Equipment/furniture purchased for a reasonable accommodation
is the property of the University and must be returned to Institutional Equity.
*Essential Function: What you have to be able to do to achieve the desired results of your job. Why functions could be considered
The position exists to perform the function.
There are a limited number of other employees available to perform the function, or among whom the function can be distrib-
A function is highly specialized, and the person is hired for special expertise or ability to perform it.
The ADA prohibits employment discrimination against qualified individuals with disabilities. A qualified individual with a disability is:
an individual with a disability who meets the skill, experience, education, and other job-related requirements of a position held
or desired, and who with or without a reasonable accommodation*, can perform the essential functions* of a job.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II
from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by
this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medi-
cal information. "Genetic information," as defined by GINA, includes an individual's family medical history, the results of an individual's
or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.
Michigan Technological University is an equal opportunity educational institution/equal opportunity employer, which includes providing equal opportunity for
protected veterans and individuals with disabilities and complies with the guidelines of the Americans with Disabilities Act.